A new study in Reproductive Health suggests that surgical removal of ovarian endometriomas before IVF or ICSI may not improve fertility outcomes, raising questions about whether routine surgery is necessary for all patients.
Surgery and IVF: what the study investigated
Endometriosis is a common gynaecological condition that can affect fertility. Ovarian endometriomas, sometimes called “chocolate cysts,” are frequently found in women undergoing assisted reproductive treatment. Traditionally, many patients have surgery before starting IVF or ICSI in the hope of improving egg yield and embryo quality.
To examine whether this approach is beneficial, researchers analysed 1,456 IVF/ICSI cycles between 2017 and 2022. Patients were divided into three groups:
Control group (no endometriosis)
Pre-EMS group (endometriomas not operated on)
Post-EMS group (endometriomas surgically removed)
The analysis used propensity score matching (PSM) to balance key fertility factors, including age, antral follicle count (AFC), body mass index (BMI), and anti-Müllerian hormone (AMH) levels.
Key findings
After matching, the endometriosis groups had lower fertilisation and embryo development rates compared with controls. However, live birth rates were similar, regardless of whether patients had undergone endometrioma surgery.
Importantly, women with advanced-stage endometriosis who had surgery showed fewer retrieved oocytes, lower ovarian sensitivity, and fewer embryos compared with those who did not undergo surgery.
Predictive analysis revealed that AMH and AFC were useful markers for identifying patients at risk of reduced embryo quality, but neither surgery nor markers such as endometrioma size predicted live birth outcomes.
Clinical implications
The findings suggest that routine cystectomy before IVF/ICSI may not be necessary for all women with endometriomas. The authors conclude that after ruling out malignancy, asymptomatic patients with low ovarian reserve (AMH ≤ 1.17 ng/mL or AFC ≤ 7) should not undergo surgery before assisted reproduction.
These results support a more individualised approach to fertility care, focusing on ovarian reserve and disease stage rather than routinely recommending surgery.
Reference
Jin W et al. Should patients undergo endometrioma surgery before IVF/ICSI? a retrospective study with propensity score matching. Reprod Health. 2025;DOI: 10.1186/s12978-025-02141-8.
